Every finding on record at New Century Hospice, Inc.

Upon patient record review 1 of 19 records (Patient #11) did not have evidence in the patient record that the hospice interdisciplinary group, in consultation with the individual's attending physician (if any), completed the comprehensive assessment no later than 5 calendar days after the election of hospice care. Patient #11: The patient was admitted on 8/20/24. The record indicated that the spiritual assessment was completed on 8/26/24.

Upon patient record review 2 of 19 records (Patient #3,#13) did not have evidence in the patient record that the comprehensive assessment identifies the spiritual needs related to the terminal illness that must be addressed in order to promote the hospice patient's well-being, comfort, and dignity throughout the dying process. Patient #3,#13: There was not evidence of a spiritual assessment.

Upon patient record review, 2 of 19 records (Patient #7, 10) did not have evidence in the patient record that a review was completed of all prescription and non-prescription medications, including herbal remedies that could affect drug therapy. This review includes, but is not limited to: • Effectiveness of drug therapy • Drug side effects • Actual or potential drug interactions • Duplicate drug therapy • Drug therapy currently associated with laboratory monitoring Patient #7: Phenytoin, Albuterol Aerosol, Carbamazepine, Lisinopril and Toprol were on the medication record of the hospice record but not the facility MAR. In addition Benzonatate, Ipratropium-Albuterol Nebulization and Pramipexole Dihydrochloride were on the facility MAR but not on the medication record of the hospice record. Corrected on site. Patient #10: The medication profile contained Potassium Chloride 20mEq oral packet BID. There was not evidence of a diluent. Corrected on site. In addition, Voltarin 1%, Docusate and ASA were on the hospice medication profile but not on the MAR at the facility. Also, Atorvastatin, Nasal saline gel, Eliquis, Freeze-it gel 3.5% Multi vitamins and Xyzal were on the facility MAR but not on the hospice medication profile. Corrected on site.

Upon patient record review, 1 of 19 records (Patient #13) did not have evidence in the patient record that the comprehensive assessment is updated including and by: • The hospice interdisciplinary group (in collaboration with the individual's attending physician, if any) • Changes that have taken place since the initial assessment • Information on the patient's progress toward desired outcomes • Reassessment of the patient's response to care • The assessment update must be accomplished as frequently as the condition of the patient requires, but no less frequently than every 15 days Patient #13: The record indicated an assessment by the RN on 10/3/24. There was not evidence of an update until 10/24/24.

Upon patient record review, 4 of 19 records (Patient #7,#10,#13,#14) did not have evidence the plan of care includes all services necessary for the palliation and management of the terminal illness and related conditions, including medications and treatments. Patient #7: Benzonatate, Ipratropium-Albuterol Nebulization and Pramipexole Dihydrochloride were on the facility MAR but there was not evidence of an order on the hospice record. Corrected on site. Patient #10: The record contained an order for Potassium Chloride 20mEq oral packet BID. There was not evidence of a diluent. In addition, Atorvastatin, Nasal saline gel, Eliquis, Freeze-it gel 3.5% Multi vitamins and Xyzal were on the facility MAR but there was not evidence of an order on the hospice record. Corrected on site Patient #13: Nurse documentation dated 9/10/24 indicated that the patient had a suprapubic catheter that needed to be changed 2x in 1 week. The CTI dated 9/10/24 indicated that the suprapubic catheter got plugged yesterday. There was not evidence of an order to irrigate or change the catheter. Corrected on site. Patient #14: The record indicated a prn visit on 10/6/24 due to the caregiver stating that the patient's BP was 90's/40's. Documentation indicated that the nurse advised to hold all BP medications and they were removed from the pill box. There was not evidence of an order from the physician to hold the BP medications.

Upon patient record review, 3 of 19 records (Patient #1,#12,#13) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. Patient #1: The record indicated a volunteer frequency was initiated on 10/4/24. There was not evidence of a visit. Patient #12: The social work visit frequency was 1m1, 2m2, 1m1 for the benefit period beginning 7/12/24. The record indicated only one visit in August and one visit in September. Patient #13: The visit frequency for the skilled nurse was 1w14. There was not evidence of a visit for the week of 10/13/24-10/19/24.

Upon patient record review, 1 of 19 records (Patient #12) did not have evidence in the patient record that hospice aide assignments and duties are: • Assigned to a specific patient by a registered nurse that is a member of the interdisciplinary group • Written patient care instructions, including alerts and precautions for a hospice aide must be prepared by a Registered Nurse who is responsible for the supervision of a hospice aide as specified under paragraph (h) of 418.76 Patient #12: The aide plan of care contained an alert/precaution for oxygen precautions. There was not evidence in the record that the patient was on oxygen. Corrected on site.

Upon patient record review 4 of 19 records (Patient #1,#2,#6,#7) did not have evidence of documentation in the patient record that a hospice aide provides services that are: • Ordered by the interdisciplinary group • Included in the plan of care Patient #1: The aide plan of care indicated for the task of shower weekly and shampoo the first visit of the week. Visit frequency was 3X/week. For the weeks beginning with 10/6/24, 10/13/24 and 10/30/24, documentation for the shower was with every visit and documentation for the shampoo was 2 times for the week of 10/6/24. Patient #2: The aide plan of care indicated for a shampoo to be performed at the second visit of the week. Visit frequency was 3x/week. For the week starting 9/15/24, the documentation revealed not needed at all 3 visits. For the weeks beginning 9/22/24 and 10/6/24, documentation revealed a shampoo was performed at 2 visits. For the weeks starting 9/29/24 and 10/13/24, a shampoo was performed at all visits. Patient #6: The aide plan of care indicated to provide shave and hair care the first visit of every week. Shave and hair care were performed at all visits in 3 of 4 weeks. Patient #7: Effective 8/14/24, the aide visit frequency was 2 aides 3x/week. On 10/14/24, 1 aide documented a shampoo was provided and the 2nd aide documented not needed. On 10/23/24 and 10/25/24, one aide documented yes to a shower and a bed bath and the second aide documented not needed.

Upon patient record review 1 of 19 records (Patient #13) did not have evidence of documentation in the patient record that a Registered Nurse made an on-site visit to the patient's home no less frequently than every 14 days to assess the quality of care and services provided by the hospice aide and to ensure that services ordered by the hospice interdisciplinary group meet the patient's needs. Patient #13: The record indicated that aides visited the patient 2x/week. There was not evidence of an aide supervisory visit between 10/3/24 and 10/24/24.

Upon observation, there was no evidence the annual report documents the use of volunteers providing day to day administrative and/or direct patient care services in an amount that, at a minimum, equals 5 percent of the total patient care hours of all paid hospice employees and contract personnel. Documentation reveals the annual percentage of volunteer usage for the year 2023 was < 4%.

Upon patient client record review, 1 of 19 records (Patient #3) did not have evidence that each patient record contains: • Signed election statement in accordance with 418.24 Patient #3: The record indicated that the patient/representative wished to receive the Patient Notification of Hospice Non-Covered Items, Services, and Drugs. There was not evidence that this was furnished.

Upon patient record review, 2 of 13 (Patient #12 and #13) did not have evidence in the patient record that a review was completed of all prescription and non-prescription medications, including herbal remedies that could affect drug therapy. Patient #12 RN visit on 7/2/21 documented Oxygen at 4LPM via NC. No evidence of Oxygen on medication profile. Patient #13 RN visit 6/14/21 documented Oxygen at 3.5LPM via NC. RN visit on 6/21/21 documented Oxygen at 4LPM via NC. No evidence of Oxygen on medication profile.

Upon patient record review, 1 of 13 (Patient #4) did not have evidence in the patient record that the comprehensive assessment includes a bereavement component. Patient #4 admitted on 12/17/20 no evidence bereavement risk assessment was completed.

Upon patient record review, 2 of 13 (Patient #3 and #5) did not have evidence in the patient record that the hospice has developed an individualized written plan of care for each patient. The plan of care must reflect patient/family goals and interventions based on the problems identified in the initial, comprehensive, and updated comprehensive assessments. The plan of care must include all services necessary for the palliation and management of the terminal illness and related conditions. Patient #3 RN visit on 10/18/21 documented patient with pain in the ribcage area and taking Oxycodone. RN visit on 10/23/21 documented patient with headache, shoulder and abdominal pain and taking Oxycodone for pain. No evidence of goals related to pain. Patient #5 terminal diagnosis of Alzheimer's and secondary diagnosis of dementia. No evidence of goals and interventions related to Neurological problems identified.

Upon patient record review, 1 of 13 (Patient #4) did not have evidence the plan of care must include all services necessary for the palliation and management of the terminal illness and related conditions, including equipment and supply needs. Patient #4 order on 8/8/21 for Oxygen 3LPM via NC. No evidence of an order for Oxygen DME.

Upon client record review, 5 of 13 (Patient #4,9,10,12,13) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. Patient #4 order on 8/8/21 for oxygen 3LPM via NC prn for shortness of breath. RN visit on 10/13/21 documented patient on oxygen at 2LPM. Patient #9 oxygen ordered at 3LPM via NC. RN documentation on 9/24/21, 9/28/21, 9/29/21, 10/7/21 and 10/22/21 provided conflicting documentation of Oxygen at 2 and 3LPM via NC. Confirmed Oxygen at 3LPM and that documentation conflicted with various nurses providing care. Patient #10 initial plan of care dated 6/14/21 included Oxygen 4LPM via NC continuous. RN visits on 9/8/21, 9/15/21 and 9/22/21 documented Oxygen range of 2-4LPM with patient on 2.5LPM via NC. Patient #12 RN visit on 7/2/21 documented Oxygen at 4LPM via NC. No evidence of an order for Oxygen 4LPm via NC. Patient #13 RN visit 6/14/21 documented Oxygen at 3.5LPM via NC. RN visit on 6/21/21 documented Oxygen at 4LPM via NC. No evidence of an order for oxygen.

Upon observation, there was no evidence the hospice follows acceptable standards of practice to prevent the transmission of infections and communicable diseases, including standard precautions. Patient #2 during RN visit with surveyor, the RN cleaned the equipment after use and placed them directly on the bedside table and not on the barrier as per the agency bag technique procedure.

Upon patient record review, 1 of 9 applicable (Patient #2) did not have evidence in the patient record that hospice aide assignments and duties include which tasks are to be provided and the frequency of those tasks. Patient #2 aide care plan dated 6/29/21 included change bed/linen the third visit of the week, the aide visit frequency was ordered as 2x/week.

Upon patient record review 4 of 9 applicable (Patient #1, #5, #8 and #9) did not have evidence documentation in the patient record that a hospice aide provides services that are: • Ordered by the interdisciplinary group • Included in the plan of care Patient #1 aide care plan dated 9/22/21 included Shampoo on Tuesday and Thursday. Aides visits on Wed 10/27/21 and Mon 11/1/21 documented Shampoo completed. Patient #5 aide care plan dated 9/28/21 included shave on the 2nd visit of the week. Aide visit frequency 3x/week. Shaving completed 3x/week on visits from 9/20/21-10/8/21 and 10/18/21-11/5/21. Shaving also completed on 10/11/21 which was the first visit of the week. Patient #8 aide care plan dated 7/15/21 included shampoo every visit. Aide visit on 10/25/21 for shampoo documented no not needed this visit. Patient #9 aide care plan dated 8/11/21 included change bed/linen on the 1st and 3rd visit of the week. Change bed/linen was performed 3x/week from 10/1/21-11/5/21.